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Executive Summary: Pain control for patients undergoing thoracic surgery is essential for their comfort and for improving their ability to function after surgery, but it can significantly increase costs. Here, we demonstrate how time-driven activity-based costing (TDABC) can be used to assess personnel costs and create process-improvement strategies.We used TDABC to evaluate the cost of providing pain control to patients undergoing thoracic surgery and to estimate the impact of specific process improvements on cost. Retrospective healthcare utilization data, with a focus on personnel costs, were used to assess cost across the entire cycle of acute pain medicine delivery for these patients. TDABC was used to identify possible improvements in personnel allocation, workflow changes, and epidural placement location and to model the cost savings of those improvements.We found that the cost of placing epidurals in the preoperative holding room was less than that of placing epidurals in the operating room. Personnel reallocation and workflow changes resulted in mean cost reductions of 14% with epidurals in the holding room and 7% cost reductions with epidurals in the operating room. Most cost savings were due to redeploying anesthesiologists to duties that are more appropriate and reducing their unnecessary duties by 30%. Furthermore, the change in epidural placement location alone in 80% of cases reduced costs by 18%. These changes did not compromise quality of care.TDABC can model personnel costs and process improvements in delivering specific healthcare services and justify further investigation of process improvements.

Purpose: To discuss the cost-benefit performance (CBP) and establish a medical fee system for robotic-assisted thoracic surgery (RATS) under the Japanese National Health Insurance System (JNHIS), which is a system not yet firmly established., Methods: All management steps for RATS are identical, such as preoperative and postoperative management. This study examines the CBP based on medical fees of RATS under the JNHIS introduced in 2016., Results: Robotic-assisted laparoscopic prostatectomy (RALP) and robotic-assisted partial nephrectomy (RAPN) now receive insurance reimbursement under the category of use of support devices for endoscopic surgery ($5420 and $3485, respectively). If the same standard amount were to be applied to RATS, institutions would need to perform at least 150 or 300 procedures thoracic operation per year to show a positive CBP ($317 per procedure as same of RALP and $130 per procedure as same of RAPN, respectively)., Conclusion: Robotic surgery in some areas receives insurance reimbursement for its "supportive" use for endoscopic surgery as for RALP and RAPN. However, at present, it is necessary to perform da Vinci Surgical System Si (dVSi) surgery at least 150-300 times in a year in a given institution to prevent a deficit in income.

Background: Department of Veterans Affairs (VA) administrative cost data bases contain inaccuracies and do not provide patient-level data., Objective: To describe methods of VA cost determination that are appropriate for specific types of studies and to exemplify these methods with case studies., Research Design: VA utilization and cost data sources are described, and their limitations highlighted. Strategies for determining costs are discussed for health care that is critical to the study, for other types of health care, and for new programs or interventions. Three case studies are presented to illustrate cost-finding methods., Results: A hybrid approach to determining VA costs is discussed. For health care that is critical to the study, administrative data can be replaced or supplemented with primary data, information from the fiscal or other services, or non-VA data. Primary data are also needed to evaluate new programs or interventions. Less intensive data gathering methods can be used for health care that is not central to the study. The first case study illustrates cost determination for a randomized controlled trial, using an example of alternative ways of maintaining hemodialysis access graft patency. The second case study illustrates the determination of costs for all outpatient procedures to use in billing for veterans with private health insurance. The third case study describes the estimation of cost savings from regionalizing open heart surgery., Conclusions: Despite problems with VA administrative cost data, accurate VA costs can be determined.